mmpc - National Indian Health Board

Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
F. Cap on Rates Charged for Contract Health Services.
Modeling on the Medicare Provider Agreement provision that caps the amount a hospital can charge
for services purchased by the Department of Veterans Affairs, in 2003 Congress enacted a similar
limitation on the amount a Medicare participating hospital may charge for services purchased by
Indian health programs operated by the IHS, Tribes, and Tribal Organizations, and urban Indian
organizations (I/T/Us). As a condition for participation in Medicare, such hospitals must accept
patients referred by I/T/Us in accordance with the admission practices, payment methodology, and
payment rates set forth in Secretarial regulations, and may accept no more than the payment rates set
by the Secretary. 38 This statutory rate cap is often referred to by the shorthand “Medicare-like rates.”
In regulations issued by IHS and CMS in 2007, the maximum amount a Medicare hospital is permitted
to accept for a service purchased by an I/T/U is the applicable Medicare rate. 39
These statutory and regulatory actions are intended to enable I/T/Us to achieve greater economies for
the services they must purchase for their Indian patients with funds appropriated for contract health
services.
G. Indian-Specific Provisions Designed to Ensure Indian Access to the Health Insurance
Exchanges
The Patient Protection and Affordable Care Act (ACA) was enacted by Congress in 2010 in order to
reform the health insurance market and make health insurance more accessible and affordable for all
Americans. It imposes a responsibility on most Americans to acquire or maintain health insurance
coverage, and contains a number of provisions intended to strengthen health insurance consumer
protections and enhance the health care workforce. Congress included a number of provisions
designed to ensure that Indians could take advantage of the new reforms. We highlight several of
these below.
Exemption from Penalty for Failure to Comply with the Individual Mandate. Although Congress
designed the law to make nearly all Americans responsible for acquiring or maintaining
acceptable levels of health insurance coverage, Congress specifically exempted members of
Indian Tribes from the tax penalty for failure to obtain acceptable coverage. 40 This provision is
38 42 U.S.C. §1395cc(a)(1)(U), as added by the Medicare Modernization Act of 2003 (P.L. 108-173).
39 72 Fed. Reg. 30706 (June 4, 2007), adding Subpt. D to 42 C.F.R. Part 136, and adding §489.29 to 42 C.F.R. Part 489.
These regulations became effective on July 5, 2007.
40 26 U.S.C. §5000A(e)(3).
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